MBBS MD DNB
National Board of Medicine
Physician and Cardiologist
New Delhi, India
JAYPEE BROTHERS MEDICAL
PUBLISHERS (P) LTD
New Delhi • Panama City • London • Dhaka • Kathmandu
EchoEchoEchoEchoEcho MaMaMaMaMade Eade Eade Eade Eade Easysysysysy®®®®®
Ms Prem Luthra
Mr Prem Luthra
Who guide and bless me
PrPrPrPrPreface teface teface teface teface to the Thiro the Thiro the Thiro the Thiro the Third Editiond Editiond Editiond Editiond Edition
Ever since the second edition of Echo Made Easy was published
five years back, there have been tremendous advancements
in the field of echocardiography. To name a few, three-
dimensional technique, tissue-Doppler study and myocardial-
contrast imaging have gained considerable popularity.
Nevertheless, there remains an unmet need for a simplistic
book on basic echocardiography for the uninitiated reader. It
gives me immense pleasure to present to cardiology students,
resident doctors, nurses and technicians working in cardiology
units, this vastly improved third edition of Echo Made Easy.
The initial chapters will help the readers to understand the
principles of conventional echo and color-Doppler imaging, the
various echo-windows and the normal views of cardiac
structures. The abnormalities observed in different forms of
heart disease including congenital, valvular, coronary,
hypertensive, myocardial, endocardial and pericardial diseases
have been discussed under separate sections. Due emphasis
has been laid on diagnostic pitfalls, differential diagnosis,
causative factors and clinical significance.
Those who have read the previous editions of Echo Made
Easy will definitely notice a remarkable improvement in the
layout of the book. Readers will appreciate a bewildering array
of striking figures and impressive tables. For this, I am extremely
grateful to Dr Rakesh Gupta, an expert in echocardiography of
international repute. He has been very kind and generous in
providing me with real-time images from his vast and valuable
Echo Made Easyviii
collection. I am also very thankful to M/s Jaypee Brothers
Medical Publishers (P) Ltd, New Delhi, India, who infuse life
into subsequent editions of all my books, by virtue of their
typesetting and artwork expertise. Do keep pouring with your
comments and criticism. Bouquets and brickbats are both
welcome. Bon voyage through Echo Made Easy, third edition.
PrPrPrPrPreface teface teface teface teface to the Fo the Fo the Fo the Fo the Fiririririrssssst Editiont Editiont Editiont Editiont Edition
Ultrasound has revolutionized clinical practice by providing the
fifth dimension to physical examination after inspection,
palpation, percussion and auscultation. Echocardiography is the
application of ultrasound for examining the heart. It is a practi-
cally useful, widely available, cost-effective and noninvasive
diagnostic tool. Usage of echo is rapidly expanding with more
and more clinicians requesting for and interpreting it to solve
vexing clinical dilemmas.
While I was preparing the manuscript of this book, many a
time two questions crossed my mind. First, is such a book really
required? And second, am I the right person to write it? At the
end of the day, I, somehow, managed to convince myself that
a precise and practical account of echocardiography is indeed
required and that an academic Physician like myself can do
justice to this highly technical subject.
The book begins with the basic principles of ultrasound and
Doppler and the clinical applications of various echo-modalities
including 2-D echo, M-mode scan, Doppler echo and color-
flow mapping. This is followed by an account of different echo-
windows and normal echo-views along with normal values and
dimensions. The echo features of various forms of heart disease
such as congenital, valvular, coronary and hypertensive
disorders are individually discussed. Due emphasis has been
laid on pitfalls in diagnosis, differentiation between seemingly
similar findings, their causation and clinical relevance. Under-
standably, figures and diagrams can never create the impact
of dynamic echo display on the video-screen. Nevertheless,
they have been especially created to leave a long-lasting visual
Echo Made Easyx
impression on the mind. In keeping with the spirit of simplicity,
difficult topics like complex congenital cardiac disease,
prosthetic heart valves and transesophageal echocardiography
have been purposely excluded.
The book is particularly meant for students of cardiology as
well as keen established clinicians wanting to know more about
echo. If I can coax some Physicians like myself to integrate
echocardiography into their day-to-day clinical practice, I will
feel genuinely elated for a mission successfully accomplished.
I am extremely grateful to:
• My school teachers who helped me to acquire good
command over English language.
• My professors at medical college who taught me the science
and art of clinical medicine.
• My heart patients whose echo-reports stimulated my gray
matter and made me wiser.
• Authors of books on echocardiography to which I referred
liberally, while preparing the manuscript.
• Dr Rakesh Gupta who has been kind and supportive in
providing me with excellent images.
• My readers whose generous appreciation, candid comments
and constructive criticism constantly stimulate me.
• M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi,
India, who repose their unflinching faith in me and provide
encouragement along with expert editorial assistance.
1. What is an Echo? 1
• Principles of Ultrasound 1
• Principles of Doppler 6
2. Conventional Echo 15
• Two-dimensional (2-D) Echo 15
• Motion-mode (M-Mode) Echo 17
• Continuous Wave (CW) Doppler 18
• Pulsed Wave (PW) Doppler 19
• Clinical Applications of Echo 20
3. Color Doppler Echo 23
• Principles of Color Doppler 23
• Applications of Color Doppler 28
4. The Echo Windows 33
• Transthoracic Echo 33
• Standard Echo Windows 34
• Transesophageal Echo 43
• Future Directions in Echo 46
5. Normal Views and Values 51
• Echo Interpretation 51
• Scanning Sequence 51
• What is Normal? 53
Echo Made Easyxvi
• Aortic Regurgitation 214
• Pulmonary Stenosis 225
• Pulmonary Regurgitation 228
14. Pericardial Diseases 233
• Pericardial Effusion 233
• Cardiac Tamponade 237
• Constrictive Pericarditis 240
15. Endocardial Diseases 243
• Classification of Endocarditis 243
• Predisposing Cardiac Lesions 244
• Indications for Serial Echoes 245
• Echo Features of Endocarditis 245
16. Intracardiac Masses 253
• Cardiac Tumors 253
• Left Atrial Myxoma 254
• Atrial Thrombus 258
• Ventricular Thrombus 261
17. Thromboembolic Diseases 265
• Indications for Echo in CVA 265
• Thromboembolism in Mitral Stenosis 267
18. Systemic Diseases 269
1 What isWhat isWhat isWhat isWhat is
an Echo?an Echo?an Echo?an Echo?an Echo?
PRINCIPLES OF ULTRASOUND
• Sound is a mechanical disturbance produced by passage of
energy through a medium which may be gas, liquid or solid.
Every sound has a particular frequency, a wavelength, its
own velocity and an intensity.
• Sound energy is transmitted through a medium in the form
of cycles or waves. Each wave consists of a peak and a
trough. The peak coincides with adjacent group of molecules
moving towards each other (compression phase). The trough
coincides with adjacent group of molecules moving away
from each other (rarefaction phase).
• Frequency of sound is the number of times per second,
sound undergoes a cycle of rise and fall. It is expressed in
cycles per second, or hertz (Hz) and multiples thereof.
1 hertz (Hz) = 1 cycle per second
1 kilohertz (KHz) = 103 Hz = 1000 Hz
1 megahertz (MHz) = 106
Hz = 1000000 Hz
• Frequency is appreciated by the listener as pitch of sound.
• Wavelength is the distance travelled by sound in one cycle
of rise and fall. The length of the wave is the distance
between two consecutive peaks.
Echo Made Easy2
• Frequency and wavelength are inter-related. Since, sound
travels a fixed distance in one second, more the cycles in a
second (greater the frequency), shorter is the wavelength
• Therefore, Velocity = Frequency × Wavelength.
• Velocity of sound is expressed in meters per second (m/sec)
and is determined by the nature of the medium through which
sound propagates. In soft tissue, the velocity is 1540 m/sec.
• Intensity of sound is nothing but its loudness or amplitude
expressed in decibels. Higher the intensity of sound, greater
is the distance upto which it is audible.
• The normal audible range of sound frequency is 20 Hz to
20 KHz. Sound whose frequency is above what is audible
to the human ear (more than 20 KHz) is known as ultrasound.
• The technique of using ultrasound to examine the heart is
known as echocardiography or simply echo.
• Electricity and ultrasound are two different forms of energy
that can be transformed from one to the other by special
crystals made of ceramic such as barium titanate.
• Ultrasound relies on the property of such crystals to transform
electrical current of changing voltage into mechanical
vibrations or ultrasound waves. This is known as the
piezoelectric (pressure-electric) effect (Fig. 1.2).
Fig. 1.1: Relationship between frequency and wavelength:
A. High frequency, short wavelength
B. Low frequency, long wavelength
What is an Echo? 3
• When electrical current is passed through a piezoelectric
crystal, the crystal vibrates. This generates ultrasound waves
which are transmitted through the body by the transducer
which houses several such crystals.
• Most of these ultrasound waves are scattered or absorbed
by the tissues, without any obvious effect. Only a few waves
are reflected back to the transducer and echoed.
• Reflected ultrasound waves again distort the piezoelectric
crystals and produce an electrical current. These reflected
echoes are processed by filtration and amplification, to be
eventually displayed on the cathode-ray-tube.
• The reflected signal gives information about the depth and
nature of the tissue studied. Most of the reflection occurs at
interfaces between tissues of different density and hence a
Fig. 1.2: The piezoelectric effect in ultrasound
Echo Made Easy4
• The magnitude of electrical current produced by the reflected
ultrasound determines the intensity and brightness on the
• On the gray-scale, high reflectivity (from bone) is white, low
reflectivity (from muscle) is gray, and no reflection (from air)
is black (Table 1.1).
• The location of the image produced by the reflected
ultrasound depends upon the time lag between transmission
and reflection of ultrasound.
• Deeper structures are shown on the lower portion of the
display screen while superficial structures are shown on the
upper portion. This is because the transducer is at the apex
of the triangular image on the screen (Fig. 1.3).
• When ultrasound is transmitted through a uniform medium,
it maintains its original direction but gets progressively
scattered and absorbed.
• When ultrasound waves generated by the transducer
encounter an interface between tissues of different density
and thus different echo-reflectivity, some of the ultrasound
waves are reflected back.
• It is these reflected ultrasound waves that are detected by
the transducer and analyzed by the echo-machine.
• The wavelength of sound is the ratio between velocity and
frequency (Wavelength = Velocity/Frequency).
Echo-reflectivity of various tissues on the gray-scale
Tissue Reflectivity Shade
Bone High White
Muscle Low Gray
Air Nil Black
What is an Echo? 5
• Since wavelength and frequency are inversely related, higher
the frequency of ultrasound, shorter is the wavelength.
Shorter the wavelength, higher is the image resolution and
lesser is the penetration.
• Therefore, high frequency probes (5.0–7.5 MHz) provide
better resolution when applied for superficial structures and
in children (Table 1.2).
Fig. 1.3: Transducer is at the apex of visual display:
A. Right ventricle in the upper screen
B. Left ventricle in the lower screen
Features and applications of probes having different frequency
Frequency Penetration Resolution Study Age
(MHz) in tissue of image depth group
2.5–3.5 Good Less Deep Adults
5.0–7.5 Less Good Superficial Children
Echo Made Easy6
• Conversely, lower the frequency of ultrasound, longer is the
wavelength. Longer the wavelength, lower is the image
resolution and greater is the tissue penetration.
• Therefore, low frequency probes (2.5–3.5 MHz) provide
better penetration when applied for deeper structures and
in adults (Table 1.2).
PRINCIPLES OF DOPPLER
• The Doppler acoustic effect is present and used by us in
everyday life, although we do not realize it. Imagine an
automobile sounding the horn and moving towards you,
going past you and then away from you.
• The pitch of the horn sound is higher when it approaches
you (higher frequency) than when it goes away from you
• This means that the nature of sound depends upon the
relative motion of the listener and the source of sound.
• The change of frequency (Doppler shift) depends upon the
speed of the automobile and the original frequency of the
• Ultrasound reflected back from a tissue interface gives
information about the depth and echo-reflectivity of the tissue.
On the other hand, Doppler utilizes ultrasound reflected back
from moving red blood cells (RBCs).
• The Doppler principle is used to derive the velocity of blood
flow. Flow velocity is derived from the change of frequency
that occurs between transmitted (original) and reflected
(observed) ultrasound signal.
• The shift of frequency (Doppler shift) is proportional to ratio
of velocity of blood to speed of sound and to the original
What is an Echo? 7
• It is calculated from the following formula:
FD : Doppler shift V : Velocity of blood
Fo : Original frequency C: Speed of sound
Therefore, velocity of blood flow is:
Further refinement of this formula is:
• The original frequency (Fo) is multiplied by 2 since Doppler
shift occurs twice, during forward transmission as well as
during backward reflection.
• Cosine theta (Cos θ) is applied as a correction for the angle
between the ultrasound beam and blood flow. The angle
between the beam and flow should be less than 20o
• Cos θ is 1 if the beam is parallel to blood flow and maximum
velocity is observed. Cos θ is 0 if the beam is perpendicular
to blood flow and no velocity is detected.
• It is noteworthy that for Doppler echo, maximum velocity
information is obtained with the ultrasound beam aligned
parallel to the direction of blood flow being studied.
• This is in sharp contrast to conventional echo, where best
image quality is obtained with the ultrasound beam aligned
perpendicular to the structure being studied.
Echo Made Easy8
• Since, the original frequency value (2×Fo) is in the denominator
of the velocity equation, it is important to remember that
maximum velocity information is obtained using a low
frequency (2.5 MHz) transducer.
• There is a direct relationship between the peak velocity of
blood flow through a stenotic valve and the pressure gradient
across the valve.
• Understandably when the valve orifice is small, blood flow has
to accelerate in order to eject the same stroke volume. This
increase in velocity is measured by Doppler.
• The pressure gradient across the valve can be calculated
using the simplified Bernaulli equation:
Δ P = 4 V2
P: pressure gradient (in mm Hg)
V: peak flow velocity (in m/sec)
• This equation is frequently used during Doppler evaluation
of stenotic valves, regurgitant lesions and assessment of
• The velocity information provided by Doppler complements
the anatomical information provided by standard M-mode
and 2-D Echo.
• Analysis of the returning Doppler signal not only provides
information about flow velocity but also flow direction.
• By convention, velocities towards the transducer are
displayed above the baseline (positive deflection) and
velocities away from the transducer are displayed below the
baseline (negative deflection) (Fig. 1.4).
• The returning Doppler signal is a spectral trace of velocity
display on a time axis. The area under curve (AUC) of the
spectral trace is known as the flow velocity integral (FVI) of
that velocity display.
What is an Echo? 9
• The value of FVI is determined by peak flow velocity and
ejection time. It can be calculated by the software of most
• Careful analysis of the spectral trace of velocity also gives
densitometric information. Density relates to the number of
RBCs moving at a given velocity.
• When blood flow is smooth or laminar, most RBCs travel at
the same velocity, since they accelerate and decelerate
• The spectral trace then has a thin outline with very few RBCs
travelling at other velocities (Figs 1.5A and C). This is known
as low variance of velocities.
• When blood flow is turbulent as across stenotic valves, there
is a wide distribution of RBCs velocities and the Doppler
signal appears “filled in” (Fig. 1.5B). This is known as high
variance of velocities, “spectral broadening” or “increased
Fig. 1.4: Direction of blood flow and the polarity of deflection:
A. Towards the transducer, positive deflection
B. Away from transducer, negative deflection
Echo Made Easy10
• It is to be borne in mind that turbulence and spectral
broadening are often associated but not synonymous with
high flow velocity.
• The intensity of the Doppler signal is represented on the gray-
scale as darker shades of gray (Fig. 1.6).
• Maximum number of RBCs travelling at a particular velocity
cast a dark shade on the spectral trace. Few RBCs travelling
at a higher velocity cast a light shade.
• This is best seen on the Doppler signal from a stenotic valve.
The spectral display is most dense near the baseline reflecting
most RBCs moving at a low velocity close to the valve
• Few RBCs accelerating through the stenotic valve are at a
high velocity (Fig. 1.6B).
• The Doppler echo modes used clinically are continuous wave
(CW) Doppler and pulsed wave (PW) Doppler.
• In CW Doppler, two piezoelectric crystals are used, one to
transmit continuously and the other to receive continuously,
without any time gap.
• It can measure high velocities but does not discriminate
between several adjacent velocity components. Therefore,
CW Doppler cannot precisely locate the signal which may
Fig. 1.5: Various patterns of blood flow seen on Doppler:
A. Laminar flow across a normal aortic valve
B. Turbulent flow across stenotic aortic valve
C. Normal flow pattern across the mitral valve
What is an Echo? 11
originate from anywhere along the length or breadth of the
• In PW Doppler, a single piezoelectric crystal to first emits a
burst of ultrasound and then receives it after a preset time
gap. This time is required in order to switch-over into the
• To locate the velocity, a ‘sample volume’ indicated by a small
box or circle, is placed over the 2-D image at the region of
interest. The ‘sample volume’ can be moved in depth along
the path of PW beam indicated as a broken line, until a
maximum velocity signal is obtained (Fig. 1.7).
• PW Doppler can precisely localize the site of origin of a
velocity signal, unlike CW Doppler.
• Because of the time delay in receiving the reflected ultrasound
signal, PW Doppler cannot accurately detect high velocities
exceeding 2 m/sec.
Fig. 1.6: Doppler signal across a stenotic aortic valve:
A. Most RBCs moving at low velocity
B. Few RBCs moving at high velocity
Echo Made Easy12
• However, PW Doppler provides a spectral tracing of better
quality than does CW Doppler (Fig. 1.8).
• The single crystal of PW Doppler can emit a fresh pulse only
after the previous pulse has returned. The time interval
between pulse repitition is therefore the sum of the time taken
by the transmitted signal to reach the target and the time taken
by the returning signal to reach the transducer.
Fig. 1.7: Doppler signal from various levels of LV:
A. LV apex
B. Mid LV
Fig. 1.8: Doppler signal from a regurgitant aortic valve
showing laminar flow
What is an Echo? 13
• The rate at which pulses are emitted is known as the pulse
repetition frequency (PRF). Obviously, greater the depth of
interrogation, more is the time interval between pulse
repetition and lower is the PRF.
• Pulse repetition frequency (PRF) should be greater than twice
the velocity being measured. The PRF decreases as the depth
of interrogation increases.
• The maximum value of Doppler frequency shift that can be
accurately measured with a given pulse repetition frequency
(PRF) is called the Nyquist limit.
• The inability of PW Doppler to detect high-frequency Doppler
shifts is known as aliasing. Aliasing occurs when the Nyquist
limited is exceeded.
• Aliasing is an artificial reversal of velocity and distortion of
the reflected signal. The phenomenon of aliasing is also called
• Aliasing can be tackled by one of these modifications:
– high pulse repetition frequency
– multigate acquisition technique
– reduced depth of interrogation
– shifting of display baseline.
The modalities of echo used clinically are:
I. Image echo
• Two-dimensional echo (2-D echo)
• Motion-mode echo (M-mode echo).
II. Doppler echo
• Continuous wave (CW) Doppler
• Pulsed wave (PW) Doppler.
Different echo modalities are not mutually exclusive but
complement each other and are often used together.
All of them follow the same principle of ultrasound but differ
with respect to the manner in which reflected sound waves are
received and displayed.
TWO-DIMENSIONAL (2-D) ECHO
• Ultrasound reflected from a tissue interface distorts the
piezoelectric crystal and generates an electrical signal. The
signal produces a dot (spot) on the display screen.
• The location of the dot indicates the distance of the structure
from the transducer. The brightness of the dot indicates the
strength of the returning signal.
Echo Made Easy16
• To create a 2-D image, the ultrasound beam has to be swept
across the area of interest. Ultrasound is transmitted along
several (90 to 120) scan lines over a wide (45° to 90°) arc
and many (20 to 30) times per second.
• The superimposition of simultaneously reflected dots, builds
up a real-time image on the display screen. Production of
images in quick succession creates an anatomical
cross-section of structures. Any image frame can be frozen,
studied on the screen or printed out on thermal paper or
on X-ray film.
• 2-D echo is useful to evaluate the anatomy of the heart and
the relationship between different structures (Fig. 2.1).
• Intracardiac masses and extracardiac pericardial abnor-
malities can be noted. The motion of the walls of ventricles
and cusps of valves is visualized.
• Thickness of ventricular walls and dimensions of chambers
can be measured and stroke volume, ejection fraction and
cardiac output can be calculated.
• 2-D image is also used to place the ‘cursor line’ for M-mode
echo and to position the ‘sample volume’ for Doppler echo.
Fig. 2.1: Two-dimensional echo (2-D Echo) views:
A. Parasternal long-axis (PLAX) view
B. Apical four-chamber (A4CH) view
Conventional Echo 17
MOTION-MODE (M-MODE) ECHO
• In the M-mode tracing, ultrasound is transmitted and received
along only one scan line.
• This line is obtained by applying the cursor to the 2-D image
and aligning it perpendicular to the structure being studied.
The transducer is finely angulated until the cursor line is
exactly perpendicular to the image.
• M-mode is displayed as a continuous tracing with two axes.
The vertical axis represents distance between the moving
structure and the transducer. The horizontal axis represents
• Since only one scan line is imaged, M-mode echo provides
greater sensitivity than 2-D echo for studying the motion of
moving cardiac structures.
• Motion and thickness of ventricular walls, changing size of
cardiac chambers and opening and closure of valves is better
displayed on M-mode (Fig. 2.2).
Fig. 2.2: Motion-mode echo (M-mode Echo) levels:
A. Mitral valve (MV) level
B. Aortic valve (AV) level
Echo Made Easy18
Fig. 2.3: Continuous wave (CW) Doppler signal of stenotic aortic valve
from multiple views; maximum velocity is 3 m/sec
APX: apical 5 chamber view
RPS: right parasternal view
SSN: suprasternal notch
• Simultaneous ECG recording facilitates accurate timing of
cardiac events. Similarly, the flow pattern on color flow
mapping can be timed in relation to the cardiac cycle.
CONTINUOUS WAVE (CW) DOPPLER
• CW Doppler transmits and receives ultrasound continuously.
It can measure high velocities without any upper limit and is
not hindered by the phenomenon of aliasing.
• However, CW Doppler cannot precisely localize the returning
signal which may originate anywhere along the length or
width of the ultrasound beam (Fig. 2.3).
• This Doppler modality is used for rapid scanning of the heart
in search of high velocity signals and abnormal flow patterns.
• Since the Doppler frequency shift is in the audible range,
the audio signal is used to angulate and rotate the transducer
in order to obtain the best visual display.
Conventional Echo 19
• CW Doppler display forms the basis for placement of “sample
volume” to obtain PW Doppler spectral tracing.
• CW Doppler is used for grading the severity of valvular
stenosis and assessing the degree of valvular regurgitation.
• An intracardiac left-to-right shunt such as a ventricular septal
defect can be quantified.
• By using CW Doppler signal of the tricuspid valve, pulmonary
artery pressure can be calculated.
PULSED WAVE (PW) DOPPLER
• PW Doppler transmits ultrasound in pulses and waits to
receive the returning ultrasound after each pulse.
• Because of the time delay in receiving the reflected signal
which limits the sampling rate, it cannot detect high velocities.
• At velocities over 2 m/sec, there occurs a reversal of flow
known as the phenomenon of aliasing.
• However, PW Doppler provides a better spectral tracing than
CW Doppler, which is used for calculations (Fig. 2.4).
Fig. 2.4: Pulsed wave (PW) Doppler signal of a stenotic aortic valve
from a single view; maximum velocity is 2 m/sec
Echo Made Easy20
• PW Doppler modality is used to localize velocity signals and
abnormal flow patterns picked up by CW Doppler and color
flow mapping, respectively.
• The mitral valve inflow signal is used for the assessment of
left ventricular diastolic dysfunction.
• The aortic valve outflow signal is used for the calculation of
stroke volume and cardiac output.
CLINICAL APPLICATIONS OF ECHO
• Anatomy of heart and structural relationships.
• Intracardiac masses and pericardial diseases.
• Motion of ventricular walls and valvular leaflets.
• Wall thickness, chamber volume, ejection fraction.
• Calculation of stroke volume and cardiac output.
• Architecture of valve leaflets and size of orifice.
• Positioning for M-mode image and Doppler echo.
• Cavity size, wall thickness and muscle mass.
• Excursion of ventricular walls and valve cusps.
• Timing of cardiac events with synchronous ECG.
• Timing of flow pattern with color flow mapping.
• Grading the severity of valvular stenosis.
• Assessing degree of valvular regurgitation.
• Quantifying the pulmonary artery pressure.
• Scanning the heart for high velocity signal.
Conventional Echo 21
• Assessment of left ventricular diastolic function.
• Calculation of stroke volume and cardiac output.
• Estimation of orifice area of stenotic aortic valve.
• Localization of flow pattern seen on CF mapping.
• Localization of signal picked up on CW Doppler.
• Application of spectral tracing for calculations.
DopDopDopDopDoppler Echopler Echopler Echopler Echopler Echo
PRINCIPLES OF COLOR DOPPLER
• Color Doppler echocardiography is an automated version of
the pulsed-wave Doppler. It is also known as real-time
• Color Doppler provides a visual display of blood flow within
the heart, in the form of a color flow map.
• The color flow map is rightly called a “non-invasive angio-
gram” since it simultaneously displays both anatomical as
well as functional information.
• After a burst of ultrasound is reflected back along a single
scan-line, as in pulsed-wave Doppler, it is analyzed by the
autocorrelator of the echo-machine.
• The autocorrelator compares the frequency of the returning
signal with the original frequency. It automatically assigns a
color-code to the frequency difference.
• Analysis of several sample volumes down each scan-line
and of several such scan-lines using multigate Doppler,
creates a color-encoded map of the area being interrogated.
• The color flow map encodes information about direction as
well as velocity of blood flow. When this map is superimposed
on the image sector of interest, appropriate interpretation is
Echo Made Easy24
• The colors assigned to blood flow towards the transducer
are shades of red white colors assigned to flow away from
the transducer are hues of blue (Fig. 3.1).
• This is in accordance with the BART convention:
Blue Away Red Towards
• As the velocity of blood flow increases, the shade or hue
assigned to the flow gets progressively brighter. Therefore,
low velocities appear dull and dark while high velocities
appear bright and light.
• When blood flow at high velocity becomes turbulent, it
superimposes color variance into the color flow map. This is
seen as a mosaic pattern with shades of aquamarine, green
and yellow (Fig. 3.2).
• This reversal of color-code, as it “wraps around” and outlines
the high velocity, is the color counterpart of aliasing observed
on pulsed-wave Doppler.
• The differences between a color flow map and a spectral
trace obtained from pulsed-wave Doppler are summarized
in Table 3.1.
Fig. 3.1: Color flow map of a normal mitral valve from A4CH view
showing a red-colored jet
Color Doppler Echo 25
• The technique of color Doppler is similar to that of
conventional echo and pulsed-wave Doppler. The transducer
is placed in the usual parasternal or apical window as done
for standard echo imaging.
• Once an anatomical image is obtained, the color is turned
on. Color flow maps are automatically displayed and
superimposed on the standard echo image (Fig. 3.3).
Differences between spectral trace and color flow on Doppler
Spectral trace Color flow
Display Scan-line Flow-map
Information Direction Color
Velocity Value Shade
Turbulence Aliasing Mosaic
Fig. 3.2: Color flow map of a stenotic mitral valve from A4CH view
showing a mosaic pattern
Echo Made Easy26
• When the color map has been visualized, the transducer is
slightly angulated. This is done to optimize the visual display.
The final image is often a trade-off between an optimal
anatomical image and a good color flow map.
• The gray-scale tissue-gain setting must be just enough to
provide structural reference. Setting the tissue-gain too low
blurs the anatomical image. Setting the tissue-gain too high
induces gray-scale artefact or “background noise” and
distorts the color display (Fig. 3.4).
• The velocity-filter and color-gain settings must be optimal.
Setting the filter high and gain low may miss color flow maps
of low velocities. Setting the filter low and gain high may
introduce color artefacts from normal structures and obscure
genuine color flow maps.
• The major advantage of color Doppler echo is the rapidity
with which normal and abnormal flow patterns can be
visualized and interpreted.
• The spatial orientation of color flow mapping is easier to
comprehend for those not experienced in Doppler.
Fig. 3.3: Color flow map of ventricular outflow tract from A5CH view
showing a blue jet
Color Doppler Echo 27
Conventional wave Doppler tracings have to be understood,
• Color Doppler improves the accuracy of sampling with
pulsed-wave and continuous-wave Doppler by helping to
align the Doppler beam with the color jet. This facilitates
localization of valve regurgitation and intracardiac shunts.
• The phenomenon of aliasing, a disadvantage in pulsed-wave
Doppler, is advantageous during color flow mapping.
Introduction of color variance in the flow map is easily
recognized as a mosaic pattern.
• Like all other echo modalities, color Doppler may be limited
by non-availability of a satisfactory echo window or by
malalignment of the ultrasound beam with blood flow
• As with pulsed-wave Doppler, color Doppler is sensitive to
pulsed repetition frequency (PRF) of the transducer and the
depth of the cardiac structure being interrogated.
• Color Doppler may inadvertently miss low velocities if the
flow signal is weak. This occurs especially if the velocity
filter setting is high and the color gain setting is low.
Fig. 3.4: Color flow map of a regurgitant aortic valve from A5CH view
showing a mosaic jet
Echo Made Easy28
• Color Doppler may spuriously pick up artefacts from heart
muscle and valve tissue which falsely get assigned a color.
This occurs especially if the velocity filter setting is low and
the color gain setting is high (Fig. 3.5).
• Complex cardiac lesions may produce a multitude of blood
flows in a small area, in both systole and diastole. The result
is a confusional riot of color, hindering rather than helping
an accurate diagnosis.
APPLICATIONS OF COLOR DOPPLER
• Color Doppler can identify, localize and quantitate stenotic
lesions of the cardiac valves. It visually displays the stenotic
area and the resultant jet as distinct from normal flow.
• Stenosis of a valve produces a “candle-flame” shaped jet at
the site of narrowing. The jet color assumes a mosaic pattern
of aquamarine, green and yellow signifying increased velocity
and turbulent flow (Fig. 3.6).
• The color Doppler signal has to be parallel to the direc-
tion of blood flow or else the degree of stenosis gets
Fig. 3.5: Color flow map of the left ventricle from A5CH view showing
artefacts from the IV septum and mitral leaflets
Color Doppler Echo 29
underestimated. Angulation of the transducer to improve the
Doppler signal, inadvertently skews and distorts the
• When there is calcification of the valve leaflets or annulus,
the color flow display drops out of the image in the calcified
area. Turning up the gain to image the calcified area causes
blooming of both the anatomic image as well as the Doppler
• It would be ideal to measure the stenotic orifice from the
color Doppler view. However, this is practically difficult since
anatomical measurement requires perpendicular beam
orientation while the Doppler signal requires a parallel beam
• Color Doppler can diagnose and estimate the severity of
regurgitant lesions of the valves. It displays the regurgitant
jet as a flow-map distinct from the normal flow pattern.
• A regurgitant valve produces a color flow map in the receiving
chamber. For instance, mitral regurgitation results in a left
atrial flow map while aortic regurgitation causes a flow map
in the left ventricular outflow tract (Fig. 3.7).
Fig. 3.6: Color flow map of stenotic aortic valve from A5CH view
showing change in color to a mosaic pattern
Echo Made Easy30
• A jet interrogated along its length produces a large flow area
while scanning the same jet across reveals a smaller area.
By using multiple views and windows for interrogation, the
size and geometry of a pathological jet can be accurately
• It is necessary to angulate the transducer, in order to scan
across the length and width of the chamber being studied.
This will improve the detection of eccentric regurgitant
• Valvular regurgitation can be quantified by assessing the
depth upto which color flow can be picked up. Mild regur-
gitation is confined to the valve plane while severe
regurgitation can be mapped upto the distal portion of the
• Measuring the absolute jet area and calculating the ratio of
jet area to atrial size is also used to assess the degree of
• A ratio of less than 25% indicates mild, 25 to 50% suggests
moderate and more than 50% represents severe valvular
Fig. 3.7: Color flow map of a regurgitant mitral valve from PLAX view
showing a jet in the left atrium
Color Doppler Echo 31
• An atrial septal defect produces a mosaic color flow map
crossing from the left atrium to the right atrium. Because of
low velocity, the color map is sometimes missed (Fig. 3.8).
• A ventricular septal defect produces a mosaic color flow map
extending from the left ventricle to the right ventricle across
the septum. The width of the map approximates the size of
the septal defect.
• A patent ductus arteriosus produces a retrograde mosaic
color flow map extending from the descending aorta to the
Fig. 3.8: Color flow map of an atrial septal defect from PSAX view
showing a jet from the left atrium to right atrium
4 The EchoThe EchoThe EchoThe EchoThe Echo
• Conventional echocardiography is performed from the
anterior chest wall (precordium) and is known as
• Echocardiography can also be performed from the eso-
phagus which is known as transesophageal echo.
• For transthoracic echo, the subject is asked to lie in the
semirecumbent position on his or her left side with the head
• The left arm is tucked under the head and the right arm lies
along the right side of the body.
• This position opens the intercostal spaces through which
echocardiography can be performed, while most of the heart
is masked from the ultrasound beam by the ribs.
• Better images are obtained during expiration when there is
least ‘air-tissue’ interface.
• Ultrasound is transmitted from a transducer having a
frequency of 2.5 to 3.5 MHz for echo in adults.
• This frequency is used to study deep seated structures
because of better penetration.
Echo Made Easy34
• A transducer frequency of 5.0 MHz is suitable for pediatric
echo, since the heart is more superficial in children.
• Ultrasound jelly is applied on the transducer and it is placed
on the chest at the site of an “echo window”.
• Most of the time, the left parasternal and apical windows
are routinely used.
• The transducer has a reference line or dot on one side, in
order to orient it in the correct direction, for obtaining various
• The transducer is variably positioned, in terms of location
and direction, for different echo images.
• It can be tilted (superiorly or inferiorly), to bring into focus
the structure of interest and rotated (clockwise or
anticlockwise), to fine-tune the image.
STANDARD ECHO WINDOWS
• Standard locations on the anterior chest wall are used to
place the transducer, which are called “echo windows”
(Fig. 4.1). These are:
– left parasternal
Fig. 4.1: The standard “windows” used during echocardiography
The Echo Windows 35
– right parasternal
• Standard windows are important for two reasons:
– penetration of ultrasound waves from windows is good,
without much masking of image or absorption of
ultrasound by ribs and lungs.
– standardized echo images can be compared with studies
performed by different observers or on different occasions
by the same observer.
• Transthoracic echo may be technically difficult to perform in
the following situations:
– severe morbid obesity
– chest wall deformity
– pulmonary emphysema.
Parasternal Long-Axis View
(PLAX View) (Fig. 4.2)
• Transducer position: left sternal edge; 2nd–4th space
• Marker dot direction: points towards right shoulder.
Fig. 4.2: The parasternal long-axis (PLAX) view
Echo Made Easy36
– proximal aorta
– aortic valve
– left atrium
– mitral valve
– left ventricle
– IV septum
– posterior wall
– right ventricle
• Most echo studies begin with this view. It sets the stage for
subsequent echo views.
Parasternal Short-Axis Views
(PSAX Views) (Fig. 4.3)
• Transducer position: left sternal edge; 2nd–4th space
• Marker dot direction: points towards left shoulder
(90° clockwise from PLAX).
• By tilting the transducer on an axis between the left hip and
right shoulder, short-axis cuts are obtained at different levels,
from the aorta to the LV apex (Fig. 4.3).
• This angulation of the transducer from the base to apex of
the heart for short-axis views is known as “bread-loafing”.
Short Axis Levels (Fig. 4.3)
1. pulmonary artery
2. aortic valve level
3. mitral valve level
4. papillary muscle
5. left ventricle.
The Echo Windows 37
Pulmonary Artery (PA) Level (Fig. 4.4)
– pulmonary artery
– pulmonary valve
– RV outflow tract.
Fig. 4.3: The parasternal short-axis (PSAX) views
The Echo Windows 39
– interatrial septum
– tricuspid valve
– RV outflow tract.
Mitral Valve (MV) Level (Fig. 4.6)
– mitral valve orifice
– mitral valve leaflets
– ventricular septum
Papillary Muscle (PM) Level (Fig. 4.7)
– anterolateral PM (3o)
– posteromedial PM (7o
– anterior wall (12o to 3o)
– lateral wall (3o to 6o)
– inferior wall (6o
– IV septum (9o to 12o)
• For apical views, the subject turns back rightwards from the
left lateral position and lies more supine.
Fig. 4.6: PSAX view: mitral valve (MV) level
Echo Made Easy40
Apical 4-Chamber View
(A4CH View) (Fig. 4.8)
• Transducer position: apex of the heart
• Marker dot direction: points towards left shoulder.
– right and left ventricle
– right and left atrium
– mitral, tricuspid valves
Fig. 4.7: PSAX view: papillary muscle (PM) level
Fig. 4.8: Apical 4-chamber (A4CH) view
The Echo Windows 41
– IA and IV septum
– left ventricular apex
– lateral wall left ventricle
– free wall right ventricle.
Apical 5-Chamber View
(A5CH view) (Fig. 4.9)
• The A5CH view is obtained after the A4CH view by slight
downward tilting of the transducer. The 5th chamber added
is the left ventricular outflow tract (LVOT).
• Transducer position: as in A4CH view.
• Marker dot direction: as in A4CH view.
As in A4CH view. Additionally:
— LV outflow tract
— aortic valve
— proximal aorta.
Fig. 4.9: Apical 5-chamber (A5CH) view
Echo Made Easy42
• For subcostal view, the position of the subject is different
from that used to obtain parasternal and apical views.
• The subject lies supine with the head held slightly low, feet
planted on the couch and the knees slightly flexed.
• Better images are obtained with the abdomen relaxed and
during the phase of inspiration.
• Transducer position: under the xiphisternum
• Marker dot position: points towards left shoulder.
As in A4CH view.
• The subcostal view is particularly useful when transthoracic
echo is technically difficult because of the following reasons:
– severe morbid obesity
– chest wall deformity
– pulmonary emphysema.
• The following structures are better seen from the subcostal
view than from the apical 4-chamber view:
– inferior vena cava
– descending aorta
– interatrial septum
– pericardial effusion.
• For suprasternal view, the subject lies supine with the neck
hyperextended by placing a pillow under the shoulders. The
head is rotated slightly towards the left.
• The position of arms or legs and the phase of respiration
have no bearing on this echo window.
• Transducer position: suprasternal notch.
• Marker dot direction: points towards left jaw.
The Echo Windows 43
– ascending aorta
– pulmonary artery.
Right Parasternal View
• For right parasternal view, the subject lies in the semi-
recumbent position on the right side. The right arm is tucked
under the head and the left arm lies along the left side of
• In other words, this position is the mirror-image of that used
for the left parasternal view.
• Transducer position: right sternal edge; 2nd–4th space
• Marker dot direction: points towards left shoulder.
– aortic valve
– aortic root.
• During echocardiography, a balance has to be struck
between tissue penetration and image resolution. Low
frequency transducers have good penetration (less
attenuation) but relatively poor resolution. On the other hand,
high frequency transducers have poor penetration (more
attenuation) but better resolution.
• Anatomically speaking, the esophagus in its mid-course is
strategically located posterior to the heart and anterior to
the descending aorta. This provides an opportunity to
interrogate the heart and related mediastinal structures with
a high frequency transducer positioned in the esophagus
for better image resolution.
• The technique is known as transesophageal echocardio-
graphy or simply TEE.
Echo Made Easy44
• A miniature transducer is mounted onto a probe or
gastroscope similar to the one employed for upper
gastrointestinal endoscopy. The scope is advanced to various
depths in the esophagus to examine cardiac and related
structures. By manoeuvring the transducer and the angle of
beam from controls on the handle, different views of the
heart are obtained.
• This ‘back-door’ approach to echocardiography has both
advantages and disadvantages.
• Useful alternative to transthoracic echo if the latter is
technically difficult due to obesity, chest wall deformity,
emphysema or pulmonary fibrosis.
• Useful complement to transthoracic echo because of better
image quality and resolution due to two reasons:
– absence of acoustic barrier between the ultrasound beam
and the rib cage, chest wall and lung tissue.
– greater proximity to the heart and therefore the ability to
use higher frequency probe with vastly improved image
quality and precise spatial resolution.
• Useful supplement to transthoracic echo, which cannot
examine the posterior aspect of the heart. Structures such
as left atrial appendage, descending aorta and pulmonary
veins can only be visualized by TEE.
• It is a semi-invasive procedure which is uncomfortable to
the patient, more time consuming and carries a small risk of
serious complications such as oropharyngeal or esophageal
trauma, cardiac arrhythmias and laryngo-bronchospasm
The Echo Windows 45
• It requires short-term sedation, oxygen administration and
ECG monitoring since, there are chances of hypoxia,
arrhythmia and angina. Rarely, respiratory depression or
allergic reactions may occur.
• TEE is contraindicated in the presence of active bleeding or
coagulopathy, esophageal abnormalities, unstable cervical
arthritis and poor cardiopulmonary status (Table 4.2).
• The transesophageal echo (TEE) views are significantly
different from standard transthoracic echo views. Novel TEE
images require a comprehensive understanding of the spatial
relationship between cardiac structures.
It would be beyond the scope and against the philosophy of
this book to understand and learn these views in detail.
Nevertheless, the indications for TEE are duly mentioned at
appropriate places, in several chapters of the book.
Complications with TEE
• Esophageal rupture or perforation
• Laryngospasm or bronchopasm
• Sustained ventricular tachycardia
• Retching and vomiting
• Sore-throat and hoarseness
• Blood-tinged sputum
• Tachycardia or bradycardia
• Hypoxia and ischemia
• Transient BP rise or fall
Echo Made Easy46
FUTURE DIRECTIONS IN ECHO
• Two-dimensional echocardiography (2-D echo) provides a
2-D view of the 3-D heart. Therefore, a series of integrated
2-D views are required to mentally construct a three-
dimensional (3-D) image of the structure of the heart.
• To accurately perform this task, knowledge of the precise
relationship of each 2-D image with the other is vital but not
• For instance, while quantifying cardiac chamber volume and
function with 2-D echo, one makes certain assumptions about
cardiac geometry to apply specific formulae for calculations.
• As chambers get distorted in shape by infarction and
remodeling, these geometric assumptions lose their accuracy
as do the calculated values from formulae.
• Three-dimensional echocardiography (3-D echo) obviates
the need for cognitive 3-D reconstruction of 2-D image planes
Contraindications to TEE
• Uncooperative patient
• Poor cardiorespiratory status
• Esophageal obstruction
• Tracheoesophageal fistula
• Active bleed or coagulopathy
• Large esophageal varices
• Prior esophageal surgery
• Unstable cervical arthritis
• Atlantoaxial dislocation
The Echo Windows 47
and the compulsion of making geometric assumption about
the shape of cardiac structures for quantification.
• Besides its application in ventricular volumetric assessment,
3-D echo is particularly useful to study asymmetrical stenotic
valve orifices, eccentric regurgitant jets picked up by color
Doppler and complex structural relationships observed in
congenital heart diseases.
• The 3-D echo can be viewed from various projections by
rotation of the images, to enhance the appreciation of
• Three-dimensional echocardiography (3-D echo) has the
potential to reduce the time required for complete cardiac
• As computer hardware and software matures and transdu-
cer technology evolves, time and labor-intensive offline
image reconstruction will soon be replaced by real-time
• Three-D echo therefore has the potential to move from being
merely a research tool to being used extensively in the
Myocardial Contrast Echo
• Myocardial contrast echocardiography involves the appli-
cation of an ultrasonic contrast agent, to accurately delineate
areas of reduced myocardial blood flow or perfusion defects
related to coronary occlusion.
• The contrast agent exists as microbubbles which are
produced either by electromechanical sonication or by lipid
• Myocardial contrast imaging has the ability to enhance
qualitative as well as quantitative information pertaining to
Echo Made Easy48
• In the emergency setting, contrast imaging provides incre-
mental prognostic information in patients who have resting
abnormalities in regional wall motion.
• Patients of acute coronary syndrome with both abnormal
wall motion and abnormal perfusion have worse event-free
survival when compared to patients with normal myocardial
• In the acute setting, contrast imaging can identify patients
with the “no-reflow” phenomenon which is characterized by
lack of recovery in microvascular perfusion despite success-
ful opening of the occluded coronary artery by intervention
• The long-term prognosis of these “no-reflow” patients is
adverse and they are observed to have significant deterio-
ration in regional and global systolic function at follow-up.
• In the chronic setting, contrast imaging can also identify
viability of the perfusion bed subtended by the occluded
coronary artery, when contrast injection into an adjacent
coronary artery produces enhancement.
• This is clinical relevant because revascularization after
myocardial infarction results in improved function only when
viable myocardium is demonstrable.
• Finally, during exercise or dobutamine stress echocardio-
graphy, real-time assessment of myocardial perfusion imp-
roves the sensitivity of the test in detecting angiographically
significant stenosis, compared to wall motion analysis alone.
Tissue Doppler Imaging
• During day-to-day echocardiography, left ventricular function
is routinely evaluated by two-dimensional (2-D) and motion-
mode (M-mode) techniques.
• However, visual evaluation of LV function using these
modalities suffers from the limitations of being significantly
subjective and provides only semi-quantitative data.
The Echo Windows 49
• Moreover, visual assessment has limited ability to detect
subtle changes in LV function and in timing of wall motion,
throughout entire systole and diastole.
• Tissue Doppler imaging is a more objective and highly
quantitative method to accurately assess regional and global
left ventricular systolic and diastolic function.
• This technique can measure a variety of myocardial func-
tional parameters which include tissue velocity, acceleration,
displacement and strain rate.
• Tissue Doppler imaging has been used as a diagnostic tool
in specific situations including assessment of myocardial
ischemia, evaluation of diastolic dysfunction and differen-
tiation between restrictive cardiomyopathy and constrictive
• Myocardial ischemia is diagnosed by velocity imaging as
reduced systolic ejection velocity and higher postsystolic
shortening velocity. Findings on strain imaging are reduced
systolic shortening along with systolic lengthening.
• Heart failure with preserved ejection fraction (HFPEF)
accounts for a significant chunk of heart failure patients
particularly in the elderly population.
• These patients have isolated or predominant diastolic heart
failure allowing for the fact that ejection fraction (EF) may
fail to identify mild systolic dysfunction.
• Additionally, there are patients who do not have heart failure
but have impaired diastolic function such as patients with
systemic hypertension and diabetes mellitus.
• The characteristic findings in diastolic dysfunction observed
by tissue Doppler imaging is reduced early diastolic mitral
annulus velocity, which correlates with peak LV lengthening
Echo Made Easy50
• This abnormality is observed across the entire range of
diastolic dysfunction from impaired relaxation (reduced E/A
ratio) through pseudo-normal filling (normal E/A ratio) to
restrictive filling (increased E/A ratio).
• Patients with constrictive pericarditis have normal systolic
function and ventricular relaxation while those with restrictive
cardiomyopathy have impairment of both parameters.
• Therefore, reduced early diastolic mitral annulus velocity is
more indicative of restrictive cardiomyopathy whereas there
is substantial overlap in transmitral filling velocities between
these patients, those with constrictive pericarditis and even
5 NorNorNorNorNormal Vmal Vmal Vmal Vmal Viewsiewsiewsiewsiews
and Vand Vand Vand Vand Valuesaluesaluesaluesalues
• The echocardiogram provides a substantial amount of
structural and functional information about the heart. While
still frames provide anatomical detail, dynamic images tell
us about physiological function.
• Echocardiography is quite easy to understand, since many
echo features are based upon simple physical facts and
• Nevertheless, the value of information derived from echo
depends heavily upon who has performed the study. The
quality of an echo is highly operator dependent and
proportional to his experience and skill.
• The abnormal can only be viewed in the light of the normal.
Therefore, it is important to appreciate normal echo images
and to be familiar with normal dimensions.
A suggested schematic for a systematic and detailed
echocardiography study is as follows:
• Start with the parasternal long-axis view.
Echo Made Easy52
• Make M-mode recording at these 3 levels:
– level of aortic valve
– level of mitral valve
– level of left ventricle.
• Rotate the transducer by 90° clockwise. Angulate it from the
base to apex to obtain short-axis views at these 4 levels:
– pulmonary artery level
– aortic valve level
– mitral valve level
– papillary muscle level.
• Go on to the apical 4-chamber view. Measure ventricular
volumes in systole and diastole (to assess LV systolic
• Turn on the color flow mapping for abnormal flow patterns
due to valvular diseases or septal defects.
• Place the pulsed wave (PW) Doppler ‘sample volume’ in the
LV cavity at the tips of MV leaflets in the diastolic position
(to assess LV diastolic function).
• Angulate the transducer anteriorly to obtain the apical
5-chamber view. Place the ‘sample volume’ in the aortic valve
to obtain the flow velocity integral (FVI). Calculate the stroke
volume and from it the cardiac output.
• Use continuous wave (CW) Doppler to scan the apical
4-chamber view for high velocity signal, if abnormal flow is
observed on color flow mapping.
• Use pulsed wave (PW) Doppler to localize an abnormal flow
seen on color flow mapping or a high velocity signal picked
on CW Doppler.
• Use other echo windows (subcostal, suprasternal and right
parasternal) as and when indicated.
• Rotate the transducer by 45° anticlockwise and obtain the
apical 2-chamber view.
Normal Views and Values 53
WHAT IS NORMAL?
It must be borne in mind that normal value ranges of
echo-derived dimensions, depend upon several factors. These
factors include height, sex, age and the level of physical activity.
Normal values are higher in these subjects:
– male gender
– tall persons
– trained athletes
– elderly patients.
Therefore, correction for these factors is made by indexing
cardiac dimensions to body surface area (BSA) using the
2 height(cm) × weight(kg)
BSA(m ) =
Normal dimensions are estimated from small populations of
‘average’ persons and may not apply to unusually small or tall
subjects, to the elderly or to athletes.
Some findings on echo may be normal and must be carefully
understood to avoid overdiagnosis of heart disease (Fig. 5.1).
• Moderator band in the apical one-third of the right ventricle,
parallel to the plane of the tricuspid valve.
• False tendon in the left ventricle, extending between the
lateral papillary muscle and the IV septum.
• Eustachian valve in the right atrium, guarding the opening
of the inferior vena cava.
• Reverberation artefact in the left atrium, from calcific mitral
annulus or prosthetic aortic valve.
Echo Made Easy54
Normal Flow Patterns
• Trivial tricuspid regurgitation is observed in many subjects.
• Minimal mitral regurgitation is observed in some subjects
• Aortic regurgitation is observed only from diseased valves.
Normal Findings in Elderly
• Mild thickening of aortic valve leaflets
(misdiagnosed as aortic valve stenosis).
• Mitral annular ring calcification with regurgitation
(misdiagnosed as vegetation or thrombus).
• Reduced LV compliance, A/E ratio > 1 on Doppler
(misdiagnosed as LV diastolic dysfunction).
• Localized subaortic bulge of ventricular septum
(misdiagnosed as septal hypertrophy or HOCM).
Fig. 5.1: Normal structural variants seen on echo:
A. Moderator band in right ventricle
B. False tendon in the left ventricle
C. Mitral annular ring calcification
D. Subaortic bulge of IV septum
Normal Views and Values 55
• Most echo studies begin with the parasternal long-axis
(PLAX) view. It sets the stage for subsequent echo views.
• Traditionally, dimensions are measured using M-mode scan
which has better resolution than 2-D echo.
• However, despite this theoretical advantage, M-mode
imaging may be inaccurate unless the cursor is placed
perpendicular to the structure being measured. Practically
speaking, this is not always possible.
• In that case, measurements can instead be made from the
2-D image of PLAX view (Fig. 5.2).
• An experienced echocardiographer can often give a
reasonably good visual assessment of LV systolic function
from the PLAX view without actual measurements.
• However, this rough assessment may be unreliable for serial
evaluation of LV function and when LV volumes critically
influence the timing of a surgical intervention.
• The PLAX view gives a good visual impression of the motion
of the interventricular septum (IVS) and the left ventricular
posterior wall (LVPW) (Fig. 5.3).
Fig. 5.2: Measurement of dimensions from PLAX view
Echo Made Easy56
Parasternal Long-Axis View (PLAX View)
The PLAX view is used to measure the dimensions of the aortic
annulus, sinus of Valsalva, aortic root and the anterior aortic
swing (Fig. 5.4).
Aortic annulus 17–25 mm
Sinus of Valsalva 22–36 mm
Sinotubular junction 18–26 mm
Fig. 5.3: Motion of IVS and LVPW seen on PLAX view
Fig. 5.4: Dimensions of proximal aorta from PLAX view
Normal Views and Values 57
Aortic root (tubular) 20–37 mm
Anterior aortic swing 7–15 mm
Aortic valve orifice area 2.5–3.5 cm2
M-Mode Scan PLAX View
Aortic Valve Level (Fig. 5.5)
Aortic root diameter 20–37 mm
Aortic cusp separation 15–26 mm
Left atrial diameter 19–40 mm
Mitral Valve Level (Fig. 5.6)
AML D-E excursion 20–35 mm
AML E-F slope 18–120 mm/sec
E point to septum less than 5 mm
– The diameter of the aortic root is measured between the
leading edges of the anterior and posterior aortic walls.
– The diameter of the left atrium is measured between the
leading edges of the anterior and posterior atrial walls.
Fig. 5.5: M-mode scan PLAX view; aortic valve level
Echo Made Easy58
Ventricular Level (Fig. 5.7)
IV-septal thickness (diastolic) 6–12 mm
Posterior wall thickness (diastolic) 6–11 mm
IV-septal excursion (systolic) 6–9 mm
Posterior wall excursion (systolic) 9–14 mm
LV diameter end-diastolic (LVEDD) 36–52 mm
LV diameter end-systolic (LVESD) 24–42 mm
RV internal dimension 7–23 mm
RV free-wall thickness < 5 mm
LV fractional shortening 30–45%
LV ejection fraction 50–75%
Fig. 5.6: M-mode scan PLAX view; mitral valve level
Fig. 5.7: M-mode scan PLAX view; ventricular level
Normal Views and Values 59
– The dimensions of the left ventricle are measured just
below the free edge of the anterior mitral leaflet.
– This standard level is important in order to compare serial
studies performed on different occasions.
Parasternal Short-Axis View (PSAX View)
Pulmonary Artery Level
Pulmonary artery diameter 18–15 mm
Pulmonary outflow velocity 0.5–1.0 m/sec
(mean 0.75 m/sec)
Aortic Valve Level
Aortic root dimension 20–37 mm
Left atrial diameter 19–40 mm
Mitral Valve Level
Mitral valve orifice 4–6 cm2
Apical 4-Chamber View (A4CH View)
LV volume end-diastolic 85 + 15 ml/m2
LV volume end-systolic 35 + 5 ml/m2
Mitral inflow velocity 0.6–1.4 m/sec
(mean 0.9 m/sec)
Tricuspid inflow velocity 0.3–0.7 m/sec
(mean 0.5 m/sec)
Echo Made Easy60
Apical 5-Chamber View (A5CH View)
Aortic outflow velocity 0.9–1.8 m/sec
(mean 1.3 m/sec)
Stroke volume 32–48 ml/beat/m2
Cardiac output 2.4–4.2 L/min/m2
• The mitral valve consists of 2 leaflets:
– anterior mitral leaflet (AML).
– posterior mitral leaflet (PML).
• Motion of both the leaflets is visualized by M-mode scanning
from the PLAX view.
• The excursion of the AML can be divided into the following
waves and slopes (Fig. 5.8):
E-wave : Anterior and posterior motion
during entire diastole.
D-E slope : Anterior motion during
rapid diastolic filling.
Fig. 5.8: M-mode tracing of the mitral valve
Normal Views and Values 61
E-F slope : Posterior motion during
A-wave : Anterior motion during
atrial systolic contraction
• The amplitude of motion of the PML is less than that of the
AML and in an opposite direction.
• The tricuspid valve consists of 3 leaflets:
– large anterior leaflet (ATL),
– small septal leaflet (STL)
– tiny posterior leaflet (PTL).
• The ATL motion is visualized by M-mode scanning from the
PLAX view in the right ventricle, anterior to the IV septum.
• The excursion of the ATL is very similar to that of the AML
of mitral valve described above (Fig. 5.9).
• The STL is only recorded when there is dilatation of the
right ventricle or clockwise rotation due to emphysema.
Fig. 5.9: M-mode tracing of the tricuspid valve
Echo Made Easy62
• The amplitude of motion of the STL is less than that of the
ATL and in a direction opposite to ATL excursion.
• The PTL is not visualized on M-mode tracing.
• The aortic valve consists of 3 cusps:
– anterior right coronary cusp (RCC)
– posterior non-coronary cusp (NCC)
– middle left coronary cusp (LCC).
• The RCC and NCC are visualized by M-mode scanning from
the PLAX view (Fig. 5.10).
• During systole, the anterior and posterior cusps move away
from each other and towards the anterior and posterior aortic
• This creates a box-like systolic opening of the valve, in the
shape of a parallelogram.
• During diastole, the cusps oppose to form a central closure
line in the aortic lumen. The closure line is equidistant from
the anterior and posterior aortic walls.
Fig. 5.10: M-mode tracing of the aortic valve
Normal Views and Values 63
• The pulmonary valve consists of 3 cusps:
– posterior (left) cusp
– anterior cusp
– right cusp.
The only cusp usually recorded by M-mode scanning from
the PLAX view is the posterior (left) cusp (Fig. 5.11).
• The anterior and right cusps are infrequently visualized due
to obliquity of the valve to the ultrasound beam.
• The excursion of the posterior pulmonary leaflet can be
divided into the following slopes (Fig. 5.11):
– B-C slope : systolic opening motion
– C-D slope : open valve during systole
– D-E slope : systolic closing motion
– E-F slope : diastolic posterior motion.
Fig. 5.11: M-mode tracing of the pulmonary valve
Assessment of ventricular function, particularly of the left
ventricle, is the most common and the most important
application of echocardiography. Presence of left ventricular
dysfunction is a reliable prognostic indicator in all forms of
cardiac disease. It has important therapeutic implications and
many a time, clinical management is altered when an abnor-
mality of ventricular function is detected.
Ventricular dysfunction can be classified as:
– Left ventricular systolic dysfunction
– Left ventricular diastolic dysfunction
– Right ventricular dysfunction.
LV SYSTOLIC DYSFUNCTION
In order to understand LV systolic dysfunction, it is important
to know the normal indices of left ventricular function.
LV wall thickness in diastole
6–12 mm interventricular septum (IVS)
6–11 mm LV posterior wall (LVPW)
Echo Made Easy66
LV wall excursion in systole
3–8 mm interventricular septum (IVS)
9–14 mm LV posterior wall (LVPW)
LV internal dimension
24–42 mm at end-systole (LVESD)
36–52 mm at end-diastole (LVEDD)
LV internal volume
35 ± 5 ml at end-systole (LVESV)
85 ± 15 ml at end-diastole (LVEDV)
Fractional shortening 30–45%
(% change in LV dimension)
LV ejection fraction 50–75%
(% change in LV volume)
Echo Features of LV Systolic Dysfunction
M-Mode LV Level
• During ventricular systole, the interventricular septum (IVS)
and the left ventricular posterior wall (LVPW) move towards
• The amplitude of this motion is reduced in the presence of
LV systolic dysfunction (Fig. 6.1).
• LV internal dimension in end-systole (LVESD) and end-
diastole (LVEDD) are measured on the M-mode tracing in
the parasternal long-axis view (PLAX), at the level of mitral
valve (MV) leaflet tips.
• Measurements are taken from the endocardial lining of the
septum (IVS) to that of the posterior wall (LVPW).
• LV dimensions are increased in the presence of left
ventricular systolic dysfunction.
Ventricular Dysfunction 67
• The percentage change in LV internal dimension between
systole and diastole is called fractional shortening (FS).
LVEDD – LVESD
FS = ____________________
The normal range of fractional shortening is 30–45%.
• Reduced fractional shortening is an indicator of systolic
dysfunction of the left ventricle.
• However, in the presence of regional wall motion abnormality,
fractional shortening does not reliably reflect the overall LV
• The normal volume of the left ventricle during end-diastole
(LVEDV) is 85±15 ml.
• A volume greater than 100 ml is indicative of LV systolic
dysfunction due to myocardial disease (cardiomyopathy or
myocardial infarction) or because of volume overload (mitral
or aortic regurgitation).
Fig. 6.1: M-mode scan of the left ventricle showing:
A. Reduced excursion of IVS and LVPW
B. Increased dimension of the LV cavity
Echo Made Easy68
• The LV volume is derived from the ‘Cubed equation’
V = D3
V: volume; D: diameter
• This equation is based on the assumption that the LV cavity
is ellipsoid in shape and the major axis is twice the minor
axis (Fig. 6.2). But this is not always true.
• The LV volume derived from the Teicholz equation gives a
more realistic and accurate measurement
V = ____________
2.4 + D
• Measurement of LV dimensions can be unreliable if septal
motion is abnormal due to old infarction, left bundle branch
block or RV volume overload.
• The percentage change in LV volume between systole and
diastole is called ejection fraction (EF):
LVEDV – LVESV
EF = ___________________
The normal range of ejection fraction is 50 to 75%.
Fig. 6.2: Simulation of left ventricle cavity as an ellipsoid.
Major axis (L) is twice the minor axis (D).
LV volume = D3 by the cubed equation.
Ventricular Dysfunction 69
• Reduced ejection fraction is an indicator of LV systolic
dysfunction. However, the ejection fraction also depends
upon ventricular loading (preload and afterload).
• The normal diastolic thickness of the left ventricular walls,
that is interventricular septum (IVS) and left ventricular
posterior wall (LVPW), is 6 to 12 mm.
• Walls thinner than 6 mm indicate to stretching due to
cardiomyopathy or scarring due to myocardial infarction.
• Walls thicker than 12 mm indicate the presence of left
• Normally, the walls should thicken in systole. Reduced
systolic thickening of walls indicates presence of LV systolic
dysfunction, either global (cardiomyopathy) or regional
2-D Echo A4CH View
• 2-D echo can also be used to estimate LV volume in
end-diastole (LVEDV) and end-systole (LVESV).
• This is done by tracing the LV endocardial borders of a
systolic and a diastolic LV frame while the software of the
echo machine calculates the LV volumes.
• From these volumes, the ejection fraction (EF) is calculated:
LVEDV – LVESV
EF = ____________________
• The above method of calculating LV volume relies on manual
tracing of the ventricular endocardial outline. Alternatively,
LV volume can be calculated totally by the computer using
the Simpson’s method.
Echo Made Easy70
• By this method, the left ventricle is divided into 20 sections
of equal thickness. The computer takes multiple short-axis
slices at different levels (Fig. 6.3). The volume of each slice
is the area multiplied by its thickness. The sum of volumes
of all slices is the volume of the left ventricle.
Area of each slice = π (D/2)2
D is diameter
Thickness of slice = 1/20 × LV
LV is length
Volume of each slice = Area × Thickness
Left ventricle volume = Sum of all volumes
• The cardiac output can also be obtained using LV volumes
by the following simple calculations:
Stroke volume (SV) = LVEDV – LVESV
Cardiac output (CO) = SV × Heart rate (HR)
Fig. 6.3: Estimation of the left ventricular volume
by Simpson’s method; D is LV diameter
Ventricular Dysfunction 71
• The cardiac output as an indicator of LV systolic function
can be calculated from the peak aortic flow velocity (Vmax).
This is obtained by Doppler display of aortic outflow from
the apical 5 chamber (A5CH) view (Fig. 6.4).
• Continuous wave (CW) Doppler is used to measure higher
velocities and pulse wave (PW) Doppler for lower velocities.
PW Doppler provides a better spectral tracing.
• Before going into calculations of cardiac output, one must
know the normal indices of ventricular ejection:
Stroke volume = 32–48 ml/beat/m2
Cardiac output = 2.8–4.2 L/min/m2
Fig. 6.4: Calculation of the cardiac output from
peak aortic flow velocity (Vmax)
FVI = flow velocity integral AT = acceleration time
PEP = pre-ejection period DT = deceleration time
LVET = LV ejection time
Echo Made Easy72
Cardiac output = SV × HR
SV : stroke volume
HR : heart rate
Stroke volume = CSA × FVI
CSA: cross-sectional area
FVI : flow velocity integral
2 2 222 D
CSA r (D / 2) 0.785D
D : aortic annulus diameter (Fig. 6.5)
• The FVI is calculated by the computer software of most echo
machines as the area under curve of aortic outflow velocity
CO = 0.785 D2 × FVI × HR
• Using similar calculations, the stroke volume of the right
side of heart can be obtained using the peak pulmonary
flow velocity (Vmax) and diameter of the pulmonary valve.
Fig. 6.5: Measurement of aortic annulus diameter (D)
to calculate aortic valve area
Ventricular Dysfunction 73
• Thereafter, the ratio of pulmonary flow (Qp) to systemic flow
(Qs) which is the Qp: Qs ratio, can be calculated to quantify
a cardiac shunt (see Congenital Diseases).
Pitfalls in the Diagnosis of LV Systolic Dysfunction
• LV internal dimensions are taken between endocardial
surfaces of IVS and LVPW. Errors in measurement may
occur if a prominent papillary muscle or a calcified mitral
annulus is mistaken for the endocardial surface of LVPW.
• As a differentiating feature, only the LVPW thickens in
systole. Abnormal septal motion (e.g. LBBB) makes fractional
shortening difficult to measure.
• The normal range for LVEDD and LVESD varies with a
number of factors including age, sex, height and body
habitus. This should always be borne in mind.
• Measurement of LV dimensions can be unreliable in the
presence of abnormal wall motion due to infarction and
abnormal septal motion due to left bundle branch block or
RV volume overload.
• Reduced LV systolic function is usually but not always
associated with increased LV dimensions.
• For instance, a large akinetic segment of the LV wall following
myocardial infarction may impair LV systolic function but LV
dimensions may be within the normal range.
• An experienced echocardiographer can often give a
reasonably good visual assessment of LV systolic function
from the PLAX view, without actual measurements.
• However, this rough assessment may be unreliable for serial
evaluation of LV function and when LV volumes critically
influence the timing of a surgical intervention.
Echo Made Easy74
• There may be interobserver and even more surprisingly,
intraobserver variations in the measurement of LV
dimensions, LV volumes and therefore in the computing of
fractional shortening and ejection fraction.
• Often these are due to variations in the frame frozen for
calculations and in the delineation of the endocardial surface.
• While calculating LV volumes, certain geometrical assump-
tions are made about LV shape which are not always valid,
particularly in a diseased heart. This often occurs in regional
• Post-infarction LV remodelling increases LV sphericity and
causes alteration of the normal ellipsoid shape of the left
• When assessing LV systolic function, one must allow for
effects of volume loading and drug therapy. Fluid overload
and antiarrhythmic drugs with negative ionotropy may further
impair LV function.
• In presence of mitral regurgitation (MR), ejection fraction
(EF) may be normal despite reduced contractility of the LV.
This is because the left atrium offers less resistance to
ejection than does the aorta.
• Conversely, in presence of aortic stenosis (AS), ejection
fraction (EF) may be low despite normal contractility of the
LV. This is because the left ventricle has to overcome a high
transaortic resistance during ejection.
• Therefore, after surgery (valve repair or replacement) for
MR, the EF falls and after surgery for AS, the EF rises.
• The calculation of cardiac output from peak aortic flow
velocity by Doppler is invalid if the aortic valve is regurgitant
or stenotic, because of increased aortic flow velocity.
• The measurement of aortic valve diameter (D) at the aortic
annulus is not only difficult but any inaccuracy is magnified,
since the D value is squared.
Ventricular Dysfunction 75
Causes of LV Systolic Dysfunction
Practically, all forms of cardiac disease ultimately culminate in
LV systolic dysfunction. Prominent causes are:
• Coronary artery disease
– single large infarct
– multiple small infarcts
– triple vessel disease
• LV pressure overload
– systemic hypertension
– aortic valve stenosis
• LV volume overload
– mitral regurgitation
– aortic regurgitation
• Left-to-right shunt
– ventricular septal defect
– patent ductus arteriosus
• Primary myocardial disease
– acute viral myocarditis
– dilated cardiomyopathy
Clinical Significance of LV Systolic Dysfunction
• The presence of LV systolic dysfunction in any form of
cardiac disease carries an adverse prognostic implication.
• Patients of coronary artery disease who have LV systolic
dysfunction in addition to wall motion abnormalities have a
lower survival rate and poorer outcome after a revasculari-
zation procedure like coronary bypass surgery.
Echo Made Easy76
• When a patient of hypertension with left ventricular
hypertrophy develops LV systolic dysfunction, it indicates
the onset of the decompensated stage of hypertensive heart
• Volume overloading of the left ventricle due to valvular
regurgitation or a left-to-right shunt will ultimately cause LV
• Besides being a prognostic marker, onset of systolic
dysfunction plays a crucial role in the timing of corrective
• Presence of LV systolic dysfunction is an important criteria
for the diagnosis of dilated cardiomyopathy.
• Serial echocardiograms can not only assess the natural
history of the disease but also the response to therapy.
• Subtle abnormalities of systolic function may not be obvious
at rest but brought out by exertion or stress testing.
• Similarly, only minor systolic dysfunction may be observed
after drug treatment of heart failure, which may have caused
• Myocarditis is inflammation of the heart muscle caused by
viral (Coxsackie B), bacterial (Mycoplasma) or parasitic
(Lyme disease) infection.
• The echo features of myocarditis are similar to those of
dilated cardiomyopathy with LV systolic and diastolic dysfunc-
tion and valvular regurgitation.
• Abnormal LV wall motion is often global but may be
segmental due to patchy inflammation of the myocardium.
Ventricular Dysfunction 77
• The differentiating features of myocarditis are a short history
of febrile illness and an ECG showing resting tachycardia
with T wave inversion.
• Serial echos showing rapid improvement of LV function and
regression of mitral regurgitation favor the diagnosis of
myocarditis rather than dilated cardiomyopathy.
LV DIASTOLIC DYSFUNCTION
In recent years, LV diastolic dysfunction has attracted a great
deal of attention. Diastolic dysfunction or the inability of LV to
relax occurs in a variety of heart diseases and often predates
the decline in LV systolic performance. A recently introduced
terminology is heart failure with preserved ejection fraction or
Diastole is divided into 4 discrete periods:
• Relaxation phase: AV closure to MV opening (1)
• Early rapid filling: MV opening to end of filling (2)
• Diastasis phase: equilibration phase (3)
• Atrial systole: active atrial contraction (4)
1 and 2 comprise the phase of myocardial relaxation which is
an active energy dependent process.
3 and 4 comprise the phase of myocardial distensibility which
is a passive stiffness dependent process.
Therefore, there are 2 patterns of diastolic dysfunction:
– slow-relaxation pattern
– restrictive pattern
Echo Made Easy78
Echo Features of LV Diastolic Dysfunction
M-Mode MV Level
• Motion of the anterior mitral leaflet (AML) during normal
diastole has a characteristic M-shape (E-A pattern). In the
presence of LV diastolic dysfunction, AML excursion is
diminished, A wave is taller than the E wave and the E : A
ratio is reduced.
• These abnormalities occur due to stiffness of left ventricle
and greater atrial contribution to ventricular filling.
• These signs are neither highly sensitive nor specific for the
presence of diastolic dysfunction.
2-D Echo PLAX View
• 2-D echo cannot directly assess LV diastolic dysfunction.
However, it can detect certain associated abnormalities such
as ventricular hypertrophy, wall motion abnormality,
myocardial infiltration or pericardial thickening.
• Coexistent abnormalities of systolic function may be detected
along with LV diastolic dysfunction.
• The diastolic flow pattern from the left atrium to the left
ventricle can be assessed by pulsed wave (PW) Doppler
using the apical 4-chamber view with the sample volume in
the mitral inflow tract. This provides a good quality spectral
• In the normal heart, the transmitral flow pattern (Fig. 6.6A)
shows two discrete waves:
E wave : passive early diastolic LV filling
A wave : active late diastolic LV filling
E : A ratio : greater than 1
Ventricular Dysfunction 79
Fig. 6.6: Various patterns of mitral diastolic inflow:
A. The normal flow pattern E > A
B. Slow-relaxation pattern, A > E
C. Restrictive pattern, very tall E
Echo Made Easy80
• When myocardial relaxation is impaired due to LV
hypertrophy or myocardial ischemia, the A wave is large and
E wave is small, i.e. E : A ratio less than 1 (Fig. 6.6B). The
deceleration time (DT) of the E wave is prolonged (> 220
• In persons aged > 50 years, the E : A ratio should be less
than 0.5 to qualify for diastolic dysfunction since the A wave
is already dominant at this age.
• This is known as the “slow-relaxation pattern” and indicates
reduced LV compliance. There is increase in atrial
contribution to ventricular filling.
• When myocardial distensibility is impaired due to myocardial
infiltration or pericardial constriction, the E wave is very tall
and A wave is small (Fig. 6.6C). The deceleration time (DT)
of the E wave is short (< 150 msec).
• This is known as the “restrictive pattern” and indicates an
elevated LV end-diastolic pressure (LVEDP). The entire
ventricular inflow occurs rapidly in early diastole and the
atrium cannot distend the ventricle any further.
Pitfalls in the Diagnosis of LV Diastolic Dysfunction
• The mitral inflow pattern of LV filling is influenced by a large
number of factors besides myocardial relaxation and
• Therefore, it is inappropriate to rely only on E : A ratio as an
indicator of LV diastolic dysfunction.
• Factors that influence the mitral inflow pattern include:
– volume loading (preload and afterload)
– heart rate and cardiac rhythm
Ventricular Dysfunction 81
– left atrial systolic function
– the phase of respiration.
• Volume overloading due to mitral or aortic regurgitation
attenuates the A wave since atrial contraction cannot effect
forward flow if the ventricle is already maximally distended.
The E wave peak is also increased.
• In the presence of tachycardia, A wave is more prominent
since the diastole is shortened (greater atrial contribution).
When there is bradycardia, A wave is small since diastolic
filling is prolonged (lesser atrial contribution). Therefore, a
tall A wave carries greater significance in the presence of
• The E : A ratio, as an indicator of diastolic dysfunction, is
invalid in the presence of atrial fibrillation, complete heart
block or a prolonged P-R interval.
• In atrial fibrillation, there is no atrial contribution to ventricular
filling. In complete heart block with A-V dissociation, the E
wave and A wave occur at different times. In prolonged PR
interval, the E wave and A wave occur at the same time and
appear as a single wave.
• In an elderly person, the A wave is dominant. If the
E : A ratio is >1 or E = A with short deceleration time (DT),
it indicates the presence of an elevated LV end-diastolic
pressure (LVEDP). This is referred to as pseudo-
normalization of MV inflow pattern.
Causes of LV Diastolic Dysfunction
LV diastolic dysfunction is observed in:
• Advanced age (> 50 years)
• Left ventricular hypertrophy
• Coronary artery disease
Echo Made Easy82
• Restrictive cardiomyopathy
• Myocardial infiltration
• Pericardial constriction
Clinical Significance of LV Diastolic Dysfunction
• Diastolic dysfunction occurs due to increased stiffness of
the LV wall, which impairs diastolic blood flow from the left
atrium to the left ventricle.
• The clinical features of left heart failure may occur in
individuals with normal or near-normal LV systolic dysfunction
as assessed by echo. These are often due to diastolic
• Diastolic dysfunction is observed in a variety of cardiac
conditions. It is more sensitive than systolic dysfunction to
the effects of normal aging.
• Abnormalites of diastolic function may occur in isolation, may
coexist with systolic dysfunction or may be observed before
major systolic impairment becomes obvious. Heart failure
may be predominantly diastolic in some cases.
• LV systolic and diastolic function have to be assessed
separately since their causation and more importantly their
treatment is considerably different.
• Too simplistic a demarcation between diastolic and systolic
dysfunction is often misleading. Systole and diastole are
phases of a continuous cardiac cycle and interactions do
occur between them.
• In mild systolic dysfunction with dyskinetic areas, some regions
can continue contracting in diastole leading to shortening of
the time available for ventricular filling. This leads to
supervening diastolic dysfunction.
Ventricular Dysfunction 83
• Conversely, a poorly compliant left ventricle that fails to fill
adequately in diastole may cause a low stroke volume in
systole. This leads to additional systolic dysfunction.
• Prominent A wave can be equated to the fourth heart sound
(S4) on auscultation while a prominent E wave can be
equated to the third heart sound (S3).
RV SYSTOLIC DYSFUNCTION
Whenever echocardiography is ordered or performed, the focus
is always on the left ventricle. This is because the most common
cardiac conditions namely systemic hypertension, coronary
artery disease and valvular pathologies affect the left ventricle.
Nevertheless, the importance of the right ventricle and its role
in heart disease is being increasingly recognized.
RV internal dimension 7–23 mm
RV free-wall thickness < 5 mm
Echo Features of RV Dysfunction
• Right ventricular size and function can be evaluated by
M-mode scan from the PLAX view and 2-D echo using the
apical and subcostal 4-chamber views.
• RV dysfunction is associated with a dilated (> 23 mm) and
hypokinetic right ventricle.
• If the RV is of the same size or larger than the LV in all the
echo-views, it is abnormal. An enlarged RV becomes globular
and loses its normal triangular shape (Fig. 6.7).
• RV free-wall thickness > 5 mm is evidence of RV hypertrophy
secondary to RV pressure overload as in pulmonary
hypertension or pulmonary stenosis.
Echo Made Easy84
• Echo may reveal the underlying cause of RV dysfunction
such as a left-to-right shunt or right-sided valvular disease.
• In the presence of RV failure, the right atrium is enlarged
and the inferior vena cava is dilated beyond 2 cm, which
fails to constrict by atleast 50 percent during inspiration
• RV volume overload causes paradoxical motion of the
interventricular septum (IVS) on M-mode scan from the
parasternal long axis (PLAX) view (Fig. 6.9).
Fig. 6.7: A4CH view showing dilatation of right atrium and ventricle
Fig. 6.8: Dimension of the inferior vena cava (IVC):
A. Normal dimension
B. Dilated vena cava
Ventricular Dysfunction 85
Pitfalls in the Diagnosis of RV Dysfunction
• Echo assessment of the RV is difficult because of heavy
trabeculation, its geometrical complexity and overlap with
other chambers on imaging. Moreover, the RV is located
directly under the sternum.
• Assessment of the RV is particularly difficult in the presence
of lung hyperinflation (emphysema), pulmonary fibrosis and
previous thoracic surgery. Paradoxically, study of RV function
is all the more important in these patient subsets.
• RV function is sensitive not only to myocardial contractility
but also to loading conditions, LV contractility and septal
excursion and to intrapericardial pressure. Analysis of RV
function should take all these factors into account.
• Even in the most experienced hands, satisfactory echo
examination of the right ventricle is obtained in less than
50 percent of subjects.
Causes of RV Dysfunction
RV dysfunction is observed in:
• Left-to-right cardiac shunt: ASD, VSD
• Right-sided valvular disease: TR, PR
Fig. 6.9: M-mode scan of the right ventricle showing:
A. Increased dimension of the RV cavity
B. Paradoxical motion of the IV septum
Echo Made Easy86
• Pulmonary hypertension: PRI, SEC
• Right ventricular infarction: INF. MI
• Right ventricular dilatation: DCMP
Clinical Significance of RV Dysfunction
• Assessment of RV dysfunction plays a critical role in certain
congenital and acquired cardiac conditions where it is
important for planning treatment, timing surgical intervention
and for predicting prognosis.
• In congenital heart disease such as VSD, ASD or Fallot’s
tetralogy, assessment of RV function before and after surgery
is a useful prognostic marker.
• Similarly, timing of surgery in valvular heart disease such as
MS, PS or TR is determined by the presence or absence of
• The long-term prognosis of patients with chronic lung disease
(COPD, ILD) depends upon RV function. RV dilatation,
pulmonary hypertension and cor-pulmonale are indicators
of a poor prognosis.
• Following myocardial infarction, RV dysfunction may be
observed in the following situations:
– inferior wall infarction with RV infarction.
– anterior wall infarction with acute VSD.
RV infarction requires a different therapeutic approach
than LV infarction. RV dysfunction due to post-MI VSD in
an important cause of mortality (see Coronary Artery
• RV diastolic collapse is a reliable echo parameter of cardiac
tamponade (see Pericardial Diseases).
The term cardiomyopathy means a disease of the heart muscle.
In its strict sense, the term should only be applied to a condition
that has no known underlying cause. In that case it known as
an idiopathic cardiomyopathy.
However, the term has, through popular usage, been extended
to include conditions wherein there is an identifiable cause.
Examples of such conditions include hypertensive, ischemic,
alcoholic and diabetic cardiomyopathy.
There are three main types of cardiomyopathies:
• Dilated cardiomyopathy (DCMP)
• Restrictive cardiomyopathy (RCMP)
• Hypertrophic cardiomyopathy (HOCM)
DILATED CARDIOMYOPATHY (DCMP)
Echo Features of DCMP
M-Mode and 2-D Echo
• There is dilatation of all the four cardiac chambers particularly
of the left ventricle, which thereby assumes a more globular
shape (Fig. 7.1).
• The left ventricular end-diastolic dimension (LVEDD) exceeds
52 mm (normal is 36 to 52 mm).
Echo Made Easy88
• Reduced LV wall thickness, reduced systolic thickening and
reduced amplitude of wall motion are observed. The reduced
LV wall motion is generalized or global rather than regional.
This is known as global hypokinesia.
• The LV walls are thin or there may be mild hypertrophy which
is inadequate for the degree of LV dilatation.
• Left atrial enlargement occurs due to stretching of the mitral
annular ring which leads to functional mitral regurgitation.
• There is reduced motion of the IVS and LVPW. The
ventricular dimensions (LVESD and LVEDD) are increased.
• Due to global hypokinesia, the systolic excursion of the
interventricular septum and of the left ventricular posterior
wall are reduced.
• For the same reason, the left ventricular diameter in end-
diastole and end-systole is increased.
• Reduced fractional shortening (FS) and ejection fraction
(LVEF). The ejection fraction (EF) is low but the cardiac
output (CO) may be normal due to compensatory
Fig. 7.1: A4CH view showing an enlarged and globular
• Due to global hypokinesia, indices of left ventricular systolic
function are reduced (see Ventricular Dysfunction).
• Increased E-point septal separation (EPSS) (Fig. 7.2). It is
the distance between the farthest posterior excursion of the
septum and the E-point of the anterior mitral leaflet (AML).
The normal EPSS does not exceed 5 mm.
– The EPSS is reduced in hypertrophic obstructive cardio-
myopathy (HOCM) due to systolic anterior motion (SAM)
of anterior mitral leaflet (AML).
– Measurement of EPSS lacks utility in the presence of
mitral valve disease in which case free motion of the AML
is already impaired.
• Reduced anterior swing of aortic root during left atrial filling
(normal >7 mm)
• Reduced AV cusp separation in systole (normal >15 mm)
with premature closure of the aortic valve (Fig. 7.3).
Fig. 7.2: M-mode scan of the left ventricle showing:
• increased size of left ventricular cavity
• reduced movement of IVS and LVPW
• increased E-point septal separation
• reduced excursion of mitral leaflets